Membership - Northshore Senior Center

Why should I be a member?

When you become a member of Northshore Senior Center, you join a network of thousands of older adults and invested community members who have been empowered to build even more vibrant, healthy and inspired lives. Membership is voluntary, and we encourage people of all ages, races, creeds and cultures to join our vibrant community. Many programs fees are discounted for members versus non-members.

Membership Fees:

Individual Annual Membership: $48/year
Annual Couple Membership: $85/year
Lifetime Membership (Individual): $500
Lifetime Membership (Couple): $750
If you are interested in becoming a member but cannot afford the membership fees, please let us know! Scholarships are available. Please contact us at 425-487-2441 for more information.

Whether you choose to become a member or not, we do require you to complete a Northshore Registration Form prior to registering for classes. You can complete the Registration Form by clicking on the link below.

MEMBER FORM
NORTHSHORE SENIOR CENTER

10201 East Riverside Drive
Bothell, WA 98011
www.northshoreseniorcenter.org
(425) 487-2441

Welcome to the Northshore Senior Center Membership Form. Please fill out each line of the form and the user demographic form below. Your Information is kept confidential. After the submit button, you will be given the option to pay with credit card. If you'd like to pay by check, please make checks payable to: Northshore Senior Center and mail to: 10201 E. Riverside Drive • Bothell WA 98011.

Membership Plan(Required)

$48 Single Membership

$85 Couple/Dual Membership

$500 Lifetime Individual Membership

$750 Lifetime Couple Membership

Please check if you would like to request a scholarship

* Please be aware that ALL Membership fees are non-refundable

Please check Home Branch/Program(Required)

Bothell

Kenmore

Mill Creek

Transportation

Health & Wellness

Inclusion (additional forms required)

Adult Day Health

Other

Today's Date(Required)

PRIMARY USER

Membership Option(Required)

NEW

RENEWAL

NEW ADDRESS

Primary User Name(Required)

First M.I. Last Nickname/Salutation

Date of Birth: Month/Day/Year(Required)

Phone (H):(Required)

Cell:(Required)

Mailing Address (Including Apt#)(Required)

Street Address City State ZIP Code

Email(Required)

Emergency Contact Person:(Required)

First Last

Emergency Phone:(Required)

Relationship to Member:(Required)

Primary User - Signature(Required)

Date(Required)

I Agree

By signing this document, I release Northshore Senior Center and all of its agents from any liability for any accident, injury, illness, or damages of any kind to persons or property that might occur while as a result in attending the Northshore Senior Center and/or participating in their activities. I also authorize any pictures, videos or recordings taken of me while I am participating in NSC activities to be used in Northshore Senior Center publications. (The staff will make every effort to notify you prior to using your photograph).

MEMBER / USER / PARTICIPANT DEMOGRAPHIC FORM

THIS INFORMATION IS CONFIDENTIAL. It is important in seeking and receiving GRANT FUNDING and for PLANNING PROGRAMS. Thank you for taking the time to complete the voluntary survey.

PRIMARY USER

1. Gender

Male

Female

Other

2. Do you identify as a member of the LGBTQ community?

Yes, Lesbian, Gay, Bisexual, Questioning

Yes, Other

3. Marital Status:

4. Do you have a disability?

Yes

5. Are you homeless or living in a temporary shelter?

Yes

Prefer not to answer

6. Are you limited in the English language?

Yes

If yes primary language is:

7. Are you a refugee or immigrant?

Yes

Prefer not to answer

8. What is your race? (Check all that apply)

American Indian or Alaska Native

Asian or Asian American

Black, African American, African

Native American or Pacific Islander

White/Caucasian

Not Listed / Other

Prefer Not To Say

Unknown

If Not Listed/Other, please add below:

9. What is your ethnicity?

Hispanic/Latino

Russian/Ukrainian

South Asian

Prefer Not To Say

Other

Unknown

If Other, please add below:

10. Military Service

Yes

Prefer Not to Say

Unknown

11. Military Family Status

Self

Not Family Member

Minor Dependent

Spouse/Partner

Surviving Spouse/Partner

Other Dependent Adult

12. Are you interested in volunteering?

Yes

SECONDARY USER

Membership Option(Required)

NEW

RENEWAL

NEW ADDRESS

Secondary User Name(Required)

First M.I. Last Nickname/Salutation

Date of Birth: Month/Day/Year(Required)

Phone (H):(Required)

Cell:(Required)

Mailing Address (Including Apt#)(Required)

Street Address City State ZIP Code

Email(Required)

Emergency Contact Person:(Required)

First Last

Emergency Phone:(Required)

Relationship to Member:(Required)

Secondary User - Signature(Required)

Date(Required)

I Agree

MEMBER / USER / PARTICIPANT DEMOGRAPHIC FORM

THIS INFORMATION IS CONFIDENTIAL. It is important in seeking and receiving GRANT FUNDING and for PLANNING PROGRAMS. Thank you for taking the time to complete the voluntary survey.

SECONDARY USER

1. Gender

Male

Female

Other

2. Do you identify as a member of the LGBTQ community?

Yes, Lesbian, Gay, Bisexual, Questioning

Yes, Other

3. Marital Status:

4. Do you have a disability?

Yes

5. Are you homeless or living in a temporary shelter?

Yes

Prefer not to answer

6. Are you limited in the English language?

Yes

If yes primary language is:

7. Are you a refugee or immigrant?

Yes

Prefer not to answer

8. What is your race? (Check all that apply)

American Indian or Alaska Native

Asian or Asian American

Black, African American, African

Native American or Pacific Islander

White/Caucasian

Not Listed / Other

Prefer Not To Say

Unknown

If Not Listed/Other, please add below:

9. What is your ethnicity?

Hispanic/Latino

Russian/Ukrainian

South Asian

Prefer Not To Say

Other

Unknown

If Other, please add below:

10. Military Service

Yes

Prefer Not to Say

Unknown

11. Military Family Status

Self

Not Family Member

Minor Dependent

Spouse/Partner

Surviving Spouse/Partner

Other Dependent Adult

12. Are you interested in volunteering?

Yes

HOUSEHOLD INCOME

One Person Household

Two Person Household

ONE PERSON HOUSEHOLD

$16,031 or less

$16,032 - $26,723

$26,724 - $42,755

$42,756 or more

TWO PERSON HOUSEHOLD

$20,963 or less

$20,964 - $34,943

$34,944 - $55,919

$55,920 or more

CAPTCHA

MEMBER FORMNORTHSHORE SENIOR CENTER

PRIMARY USER

MEMBER / USER / PARTICIPANT DEMOGRAPHIC FORM

PRIMARY USER

SECONDARY USER

MEMBER / USER / PARTICIPANT DEMOGRAPHIC FORM

SECONDARY USER

What Does the Senior Center Mean to You?

MEMBER FORM
NORTHSHORE SENIOR CENTER